Provider Demographics
NPI:1881686541
Name:CARRILLO-BISLICK, RAUL TADEO (MD)
Entity Type:Individual
Prefix:MR
First Name:RAUL
Middle Name:TADEO
Last Name:CARRILLO-BISLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAUL
Other - Middle Name:
Other - Last Name:CARRILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1970 HOSPITAL VIEW WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1926
Mailing Address - Country:US
Mailing Address - Phone:352-404-8072
Mailing Address - Fax:352-404-8312
Practice Address - Street 1:1970 HOSPITAL VIEW WAY STE 2
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-404-8072
Practice Address - Fax:352-404-8312
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87534207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267028300Medicaid
FL253650100Medicaid
FL78798OtherBLUE SHIELD
FLK0026Medicare ID - Type UnspecifiedGROUP#
FL78798ZMedicare ID - Type UnspecifiedINDIVIDUAL #
BE947Medicare PIN
FL253650100Medicaid
FL78798OtherBLUE SHIELD